Ch 7 - Assessing Psychological Cognitive and Moral Development

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Chapter 7 Assessing Psychosocial, Cognitive, and Moral Development Nursing Interview Guide to Collect Subjective Data From the Client Questions Findings How old are you? Client is 20 years old Where were you born? How long have you been in this country? Client was born in the U.S. Where is your place of birth? Tell me about the places where you have lived. When? Client was born in Summit, NJ and currently lives in Millburn, NJ With what cultural group(s) do you most identify? What is your primary language? When do you speak it? Are you fluent in other languages? Client speaks English, Russian, and Uzbek What is your highest level of formal education? Currently in college Discuss your history of employment. If a person states that he is retired, inquire from what occupation(s). How do you presently make a living and maintain your everyday needs? N/A, never employed History of Present Health Concerns Describe how you are feeling right now. What concerns do you have about your health? Describe any changes you have recently experienced in your health. No health concerns Discuss any concerns you have about your body weight. No concerns about body weight What major stressors are you currently experiencing? How do you cope with stress? When you are having a problem, how do you usually handle them? Does this work? To whom do you turn when you are having a conflict/crisis? Major stressors include school and client turns to family and friends when having a problem or conflict/crisis. Do you have any troublemaking decisions? Please give me some examples of recent decisions you have had to make. Does not have any troublemaking decisions Tell me about life changes you have had to make. Need to make? How will you make these changes? No life changes previously made. Personal Health History

Nursing Interview Guide to Collect Subjective Data From the Client How would you describe yourself to others? What are your strengths? Weaknesses? Client described themselves as organized and kind. What is the best method of learning for you? Client learns best hands on Have you ever been treated (or currently being treated) for a psychological or psychiatric problem? If so, please explain if this treatment helped you deal with (or is currently helping you deal with) problems? Has never been treated for a psychological or psychiatric problem. Please tell me about any prescribed medications, herbs, or supplements you are currently taking. Please tell me about any over-the-counter medication/herbs you are currently taking. Please tell me about any current medical treatment or therapy you are undergoing. Does not currently take any prescribed medications, otc medications, herbs, or supplements. Describe any changes you have recently experienced concerning your weight? Eating? Elimination needs? Sleep? Please tell me about any allergies or sensitivities you have. No changes concerning weight, eating, or sleep. Describe any chronic illnesses with which you have been diagnosed. How has your life changed since you were diagnosed? No chronic illnesses. Family History Whom do you consider to be your family? Client considers parents and brother do be their family. Describe your life growing up as a child. Client describes childhood as comfortable. Do you have brothers? Sisters? Tell me about them and the relationships you have with them. Clinet has one brother and has a close relationship with them. Discuss any significant genetic predisposition or characteristic trait or disorder that you believe you have inherited. No significant genetic predisposition or characteristic trait or disorder. Lifestyle and Health Practices Due to the unique assessment topic of this chapter, questions related to the client’s lifestyle and health practices are addressed in the Assessing Developmental Level: Psychosocial Status section below. S 20 year old client denies any health concerns. Client denies any weight concerns. Client has never been treated for any psychological or psychiatric

problems. Client does not currently take any prescribed medications, OTC medications, herbs, or supplements. Client also denies any significant genetic predisposition or characteristic trait or disorder. Client does express school as a major stressor in life. O Client appears to be well nourished and cooperative. Client is sitting upright with good posture and seems comfortable in answering the interview questions. Client makes good eye contact. A Readiness for managing major life stressors. P Educate client on different ways to help manage and cope with stress.

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